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JUNE 2009

Population Action International uses research and advocacy to improve access to family planning and
reproductive health care across the world so women and families can prosper and live in balance with the earth.
By ensuring couples are able to determine the size of their families, poverty and the depletion of natural resources
are reduced, improving the lives of millions across the world.

List of Acronyms                  2

1 Background and Introduction     4

2 Country Context                 7

3 Methodology                     9

4 The Policy Environment for
  Reproductive Health Supplies   10

5 The Public Sector Health
  System Structure               14

6 Financing of Reproductive
  Health Supplies                16

7 Contraceptive Forecasting,
  Procurement and Logistics      20

8 Development Partners
  and Civil Society              22

9 Findings and Advocacy
  Entry Points                   27

Appendix 1: Interviews
and Contacts                     30

Appendix 2: References           31

Endnotes                         34

                            LIST OF ACRONYMS

                            AIDS     Acquired Immunodeficiency            FHI     Family Health International
                                     Syndrome                             FY      Fiscal year
                            CPR      Contraceptive Prevalence Rate        GAVI    Global Alliance for Vaccines and
                            CPTs     Contraceptive Procurement Tables             Immunizations
                            CRTU     Contraceptive and Reproductive       GFATM   Global Fund to Fight AIDS,
                                     Health Technologies, Research and            Tuberculosis, and Malaria
                                     Utilization                          GOU     Government of Uganda
                            CSO      Civil society organization           HIV     Human Immunodeficiency Virus
                            DANIDA   Danish International Development     HMIS    Health Management Information
                                     Assistance                                   System
                            DFID     Department for International         HPAU    Health Policy Analysis Unit
                                     Development, UK                      HSSP    Health Sector Strategic Plan
                            DHS      Demographic and Health Survey        ICPD    International Conference on Popu-
                            DISH     Delivery of Improved Services for            lation and Development
                                     Health                               IDP     Internally displaced person
                            DSW      German Foundation for World          IPPF    International Planned Parenthood
                                     Population                                   Federation
                            DTC      Drugs and Therapeutic Committee      IUD     Intrauterine device
                            EARHN    Eastern Africa Reproductive Health   JAF     Joint Assistance Framework
                                     Network                              JMS     Joint Medical Stores
                            EDLU     Essential Drugs List of Uganda       JSI     John Snow, Inc.
                            FP       Family planning                      KfW     German Development Bank
                            FPAU     Family Planning Association of       MDGs    Millennium Development Goals
                                     Uganda                               MMR     Maternal mortality ratio

Young people wait outside
the Naguru Teenage
Centre, which provides
reproductive health
supplies and other
(Jennifer Johnson/PAI)

MOH      Ministry of Health
MOU      Memorandum of Understanding
MSH      Management Sciences for Health
MSI      Marie Stopes International
MSU      Marie Stopes Uganda
NDA      National Drug Authority
NMS      National Medical Stores
NGO      Non-governmental organization
PAF      Poverty Action Fund
PAI      Population Action International
PEAP     Poverty Eradication Action Plan
PEPFAR   President’s Emergency Plan for
         AIDS Relief
PPD      Partners in Population and
PSI      Population Services International
RAISE    Reproductive Health Access,
         Information and Services in
RH       Reproductive health
RHCS     Reproductive health commodity
RHD      Reproductive Health Division
         (Ministry of Health)
RHU      Reproductive Health Uganda
RMA      Resource Mobilization and           A nurse demonstrates the
         Awareness                           medical supplies, including
                                             contraceptives, in stock at
STI      Sexually Transmitted Infection      a rural clinic near Mityana.
SWAp     Sector-Wide Approach                (Elizabeth Leahy/PAI)
TFR      Total fertility rate
UAC      Uganda AIDS Commission
UBOS     Uganda Bureau of Statistics
UHMG     Uganda Health Marketing Group
UNFPA    United Nations Population Fund
UNMHCP   Uganda National Minimum Health
         Care Package
UPMO     Uganda Private Midwives
URHAN    Uganda Reproductive Health
         Advocacy Network
USAID    United States Agency for
         International Development
WHO      World Health Organization


        This case study was produced by Project Resource      health supplies” is intentionally broad in order to
        Mobilization and Awareness (“Project RMA”),           encompass the wide array of supplies necessary for
        whose three organizational partners are Popula-       quality reproductive health care, including and
        tion Action International (PAI), the German           beyond family planning. However, the research
        Foundation for World Population (DSW) and             provided in these six case studies focuses on con-
        the International Planned Parenthood Federation       traceptives and condoms because of the historical
        (IPPF). The Project is funded for the period from     priority placed on these supplies, as well as the
        October 2006 to April 2010.                           challenges in monitoring and tracking the full
                                                              array of other products and medications. Contra-
        Project RMA partners operate at the global,           ceptives and condoms are the hallmark of many
        regional and national levels, working in syn-         family planning and reproductive health programs
        chronicity with each other and with the project’s     and are the primary emphasis of Project RMA’s
        overarching goal, which is “to increase tangible      advocacy efforts at the national, regional and
        financial and political commitment to sustainable     global levels, but the full range of reproductive
        reproductive health supplies through international    health supplies extends well beyond the specific
        coordination and support of national advocacy         commodities discussed in this report.
        strategy development and implementation in
        developing countries.” Project RMA has three          Uganda is one of six countries selected for inclu-
        central objectives:                                   sion for Project RMA-supported in-depth case
                                                              studies, together with Bangladesh, Ghana, Mex-
        n Promote a supportive political environment for      ico, Nicaragua and Tanzania. Countries were se-
          reproductive health (RH) supplies by enabling       lected based on the potential derived from project
          civil society organizations (CSO) and networks      partners’ work to coordinate country, regional and
          to engage in advocacy at the international and      global level advocacy efforts. This paper, together
          regional levels in a comprehensive and coordi-      with five additional case studies from other coun-
          nated manner.                                       tries and information from other sources, provides
        n Create a supportive political and financial envi-   an evidence base for national level advocacy. Each
          ronment for improving access to RH supplies at      case study is written with generalist advocates in
          the regional level.                                 mind. These can include, but are not limited to,
        n Strengthen national level advocacy on RH com-       civic leaders, parliamentarians, faith-based leaders,
          modities supplies in six partner countries in the   and community leaders.
          global south.
                                                              This report provides overview of how RH sup-
        The Project adopts the definition of reproductive     plies, specifically contraceptives and condoms, are
        health supplies established by the Reproduc-          programmed, managed and funded in Uganda. It
        tive Health Supplies Coalition, which is: “…          presents a distillation of information on policies,
        any material or consumable needed to provide          systems, budgets and key actors to help raise the
        reproductive health services. This includes, but      awareness of experienced advocates—who may
        is not necessarily limited to contraceptives for      lack technical knowledge about contraceptives—
        family planning, drugs to treat sexually transmit-    so that they strategically choose advocacy actions
        ted infections, and equipment such as that used       and targets. This information should also facilitate
        for safe delivery.” Use of the term “reproductive     collaboration and coordination with advocacy

                                                                                                                 A woman’s blood pressure
                                                                                                                 is checked at the Naguru
                                                                                                                 Teenage Centre.
                                                                                                                 (Jennifer Johnson/PAI)

efforts at the global and regional levels. Informa-     ily planning program faces different conditions in
tion and issues from one country may be useful to       ensuring contraceptive availability. For example,
other countries facing similar challenges.              programs facing reductions in donor funding may
                                                        be aware of supply constraints, but may not have
Project RMA has identified four indicators by           convened stakeholders in a forum through which
which to assess tangible results at the country level   they can address these constraints. In other cases,
in contraceptive security.1                             family planning activities may become a lower
                                                        priority as national officials cope with addressing
These are:                                              the HIV/AIDS pandemic. Here, fostering under-
                                                        standing among leaders of the crucial role that
n the existence of a contraceptive supply coordina-     RH supplies play in HIV programs is paramount.
  tion mechanism;
n the inclusion of contraceptives on the national       A third scenario might be a government that
  essential drug list;                                  is decentralizing or undergoing health sector
n a functioning government budget line item for         reform; officials must anticipate and plan for how
  contraceptive supplies; and                           to ensure uninterrupted supplies and services as
n the integration of contraceptive supplies into a      management is moved from the central to local
  financing mechanism.                                  levels. In addition to these structural issues, family
                                                        planning may be controversial in certain settings.
This document provides information to help ad-          This is particularly true for some identified sub-
vocates understand aspects of reproductive health       populations such as adolescents and unmarried
supplies in the specific case of Uganda. Every fam-     couples. Therefore, advocacy related to contracep-

          tives may be more difficult than that for other       This study identifies some potential entry points,
          public health issues such as maternal health.         blockages, technical capacities and champions.
          Linking family planning acceptance, continua-         Among audiences who may find this useful are
          tion and contraceptive security to other maternal     members of civil society, such as policy advo-
          and child health outcomes or development and          cacy groups, professional associations and youth
          poverty-alleviation goals is an important tactic.     groups; service providers; officials and staff in
          Raising awareness and facilitating policy change      various government ministries and agencies; par-
          at the country level requires carefully planned and   liamentarians; local and district level government
          informed strategies.                                  staff; decision-makers in bilateral and multilateral
                                                                aid agencies, inter-governmental organizations
          This report should be considered as helping to        and regional networks; and all advocates inter-
          form a bridge between technical experts and ad-       ested in changing policy at the country level, or
          vocates, informing the former about RH supplies       using case examples from country level to change
          and, for the latter, highlighting some key supplies   global policy.
          issues that are ripe for advocacy. This and the
          other Project RMA case studies demonstrate to
          advocates seeking policy change how RH supplies
          issues can be used to raise awareness of policy
          needs that can positively affect reproductive
          health more broadly.

Uganda’s president, Yoweri Museveni, maintains
a strong pronatalist stance, positing that a large
population leads to power and economic growth.


The family planning movement in Uganda was            members of parliament have emerged as forceful
launched in 1957 when the Family Planning As-         advocates, such support is weak or nonexistent
sociation of Uganda (FPAU) was established by a       at the highest levels. Uganda’s president, Yoweri
group of volunteers. At this time, FPAU was the       Museveni, maintains a strong pronatalist stance,
only provider of family planning services in the      positing that a large population leads to power
country.2 In 1986, the government began includ-       and economic growth. Recently, a chairperson
ing family planning in the primary health care        of the National Resistance Movement, President
package of the Ministry of Health (MOH). In           Museveni’s ruling party, in a district in northern
1995, the National Population Policy for Sustain-     Uganda spoke out in opposition to family plan-
able Development was introduced, reversing a          ning, stating that family planning advocates “will
previous requirement that married women receive       not be tolerated,” and urged his constituents to
permission from their husbands in order to use        have many children.4 Meanwhile, the newly ap-
family planning services.3 While the Ministry of      pointed state minister for planning has speculated
Health is supportive of reproductive health, and      that Uganda’s rate of high population growth can

 Indicator                                                                                 Source
 Population size (millions), 2005                                    28.7                  UN Population Division

 Population size (millions), 2025 (projected,                        53.4                  UN Population Division
 medium-fertility variant)

 Population size (millions), 2050 (projected,                        91.3                  UN Population Division
 medium-fertility variant)

 Population under age 15 (%), 2005                                   49.3                  UN Population Division

 Annual population growth rate (%), 2000-2005                         3.2                  UN Population Division

 Life expectancy at birth (years), 2000-2005                         48.1                  UN Population Division

 Total fertility rate, 2006                                           6.7                  DHS

 Contraceptive use among married women, mod-                         17.9                  DHS
 ern methods, aged 15-49 (%), 2006

 Unmet need for family planning among married                        40.6                  DHS
 women, aged 15-49 (%), 2006

 Maternal deaths per 100,000 live births, 2005                       550                   WHO

 Infant mortality rate per 1,000 live births, 2006                     76                  DHS

 Population living below national poverty line (%),                  37.7                  UNDP (Human Development Report
 1990-2004                                                                                 2007/08)

                               be attributed to limited access to electricity, and   among married women, the third-highest rate
                               suggested that infrastructure improvements would      in the world. Table 1 highlights relevant demo-
                               “lower the high population growth rate even with-     graphic indicators.
                               out birth control measures.”5
                                                                                     The apparent discrepancy between knowledge
                               The 2006 Uganda Demographic and Health                and use of contraception may be attributed
                               Survey (DHS) reports that from 1995 to 2006,          partially to cultural issues. Ideal family size among
                               the total fertility rate (TFR), the average number    women decreased slightly from 5.3 to 4.8 children
                               of children a woman will have in her lifetime,        per woman between 1995 and 2000/01, but has
                               decreased only slightly from 6.9 to 6.7 children      risen again to 5.0 children in 2006; men currently
                               per woman. Of the eastern and southern African        prefer to have a family averaging 5.7 children.6
                               countries that have completed a DHS within            Twenty-five percent of women with an unmet
                               the past ten years, Uganda has the highest TFR.       need for family planning would like to space
                               Modern contraceptive use by married women             births compared to 16 percent who want to limit
                               remains very low, but has increased significantly     births. Uganda has a high maternal mortality ratio
                               from 8 percent to 18 percent over a ten-year          (MMR) of 550 deaths per 100,000 live births.
                               period. This increase is due in part to the rising    The lifetime risk of maternal death is 1 in 25.7
                               use of injectables, which currently account for 10
                               percent of modern contraceptive use. The second
                               most common contraceptive method is the pill
                               (three percent). Despite the upward trend in con-
                               traceptive use and nearly universal knowledge of
                               modern contraceptive methods, unmet need for
                               family planning is startlingly high at 41 percent

Adolescent students and
their parents attend a
presentation on reproduc-
tive health and gender at a
school in Malangala village.
(Elizabeth Leahy/PAI)


The Uganda case study was conducted using a           Stage Two: In December 2007, April 2008 and
two stage research process.                           March 2009, Project RMA staff interviewed key
                                                      stakeholders including representatives of the Min-
Stage One: Through an initial period of docu-         istry of Health and other governmental agencies;
ment review, Project RMA staff analyzed policy        donor agencies; and non-governmental organiza-
documents relevant to reproductive health             tions (NGOs) active in RH supplies (see Appen-
programs and the associated supplies (detailed        dix One for a complete list of interviewees).
in section four). A review of each document
identified the programmatic emphasis, goals and
objectives of the activities described, and indica-
tors of success.

                                                                                                           Supplies are loaded for
                                                                                                           distribution to lower levels
                                                                                                           of the health system.
                                                                                                           (Susan Anderson/PAI)

         Despite disinterest and occasional opposition at
         high levels, Uganda has reasonable reproductive          Uganda’s policies and strategies are written at
         health policies that are currently being enhanced by     the central level, but districts are responsible for
         the introduction of new strategies for contraceptive     implementation, leaving a major gap. In facili-
         security and other issues. However, policy imple-        ties, staff are likely to be unaware of the targets
         mentation is extremely weak. A perceived duality of      and commitments of policies, which are poorly
         concurrent support and resistance to family planning     disseminated outside of central level ministries
         may explain the inconsistency between policy forma-      and donors.
         tion and implementation. In 1995, the Population
         Secretariat produced the earliest document in support    Poverty Eradication Action Plan 2004/05 –
         of family planning, the National Population Policy       2007/08 (PEAP)
         for Sustainable Development, but some recent reports     The PEAP, produced by the Ministry of Finance,
         from the Secretariat emphasize the benefits of a large   Planning and Economic Development, was first
         population.8                                             published in 1997. It was revised in 2000 to meet
                                                                  the criteria of a Poverty Reduction Strategy Paper,
         Uganda’s policy framework is complicated by              a document that is required by the World Bank
         the rhetoric of President Museveni, who makes            and International Monetary Fund in order to
         frequent statements espousing the benefits he            qualify for debt relief. The plan addresses gender
         perceives from a rapidly growing population. In a        inequality and a commitment to the Millennium
         2008 statement, he said “‘Uganda has got much            Development Goals (MDGs). Family planning
         more natural resources than [developed coun-             and reproductive health are linked to poverty in
         tries]. How can we fail to cope with a population        the discussion of the effects of the high fertility
         of 30 million or the subsequent increases?’”9            rate on individual families’ economic situation,
         Although first Lady Janet Museveni has affiliated        and the effects of population growth on the coun-
         herself with the cause of maternal health and            try’s economic growth. A health services review
         has discussed the importance of birth spacing,           reveals that reproductive health services have not
         strong support for family planning and a broader         improved, the contraceptive prevalence rate is
         definition of reproductive health is lacking, not        too low, and there are stockouts of reproductive
         only among the presidential couple but also from         health drugs and supplies (although stockouts
         other leaders. “What is missing is a serious and         are not quantified). The PEAP suggests activities
         wide-ranging commitment from government,”                that will promote family planning in an effort to
         one stakeholder summarized. Although there               alleviate problems caused by the high fertility rate,
         is no deliberate obstruction in family planning          such as providing family planning to three million
         programs, except in the case of some individual          couples annually.
         providers and managers with contrary religious
         beliefs, the lack of political support has created       Indicators for monitoring the PEAP include:
         an environment of malaise and fatigue among              lowering the maternal mortality ratio (target of
         managers and policy-makers. The draft Roadmap            354 deaths per 100,000 births by 2007/08), rais-
         for maternal health, prepared by the MOH, notes          ing the percentage of facilities without stockouts
         that “many contradictory arguments emerge from           of various drugs, including the injectable con-
         political and religious leaders about the role of        traceptive Depo Provera (target of 60 percent by
         family planning.”10                                      2007/08), and raising the percentage of demand

Although there is no deliberate obstruction in
family planning programs, except in the case of
some individual providers and managers with
contrary religious beliefs, the lack of political
support has created an environment of malaise
and fatigue among managers and policy-makers.
met for family planning services, without a quan-       notes that family planning and emergency obstet-
tified target.                                          ric care needs are still largely unmet, and includes
                                                        an increase in the contraceptive prevalence rate for
The PEAP will be replaced by the five-year              all methods from 23 percent to 40 percent as one
National Development Plan. A draft of the Plan          of the targets. As part of the strategy to combat
could not be reviewed for this case study, but a list   HIV, a target is to improve access and availability
of proposed development objectives prepared by          of condoms to 100 percent.
the Ministry of Finance, Planning and Economic
Development included access to quality of health,       Some indicators for monitoring the HSSP II are:
family planning, and population growth and              the percentage of facilities without stockouts of
employment.11                                           various drugs, including Depo Provera, with a tar-
                                                        get of 80 percent by 2009/10; and the percentage
National Health Policy, 1999                            of health units providing emergency contracep-
The focus of the National Health Policy, pro-           tives, with a target of 60 percent by 2009/10.
duced by the Ministry of Health, is on the
implementation of the Uganda National Mini-             National Population Policy for Sustainable
mum Health Care Package (UNMHCP), which                 Development, 2008
places great importance on sexual and reproduc-         The Population Secretariat in the Ministry of
tive health and rights. Sub-topics are antenatal        Finance and Economic Planning published this
and obstetric care, family planning, adolescent         first revision to Uganda’s original 1995 population
reproductive health, and violence against women,        policy. The revision was designed to incorporate
but there is no mention of ensuring access to RH        the commitments of the International Conference
supplies. However, RH commodities are part of           on Population and Development (ICPD), the
the National Minimum Health Care Package.               Millennium Development Goals (MDGs), 2002
                                                        national census, and other developments.
Health Sector Strategic Plan 2005/06 –
2009/10 (HSSP II)                                       The policy has 11 objectives related to: integra-
Developed by the Ministry of Health as a guide          tion of population into development planning;
for short-term health sector operations, the HSSP       monitoring of population trends; analysis of
II identifies the reduction of the MMR and TFR          population trends; human capital development;
as priorities based on the UNMHCP. In address-          improved nutrition, income and environmental
ing sexual and reproductive health, the strategy        protection; health seeking behavior; reduction of

     unmet need for family planning; protection of            2014 and development of a five-year RH supplies
     vulnerable groups; urbanization; resource mobi-          procurement plan.
     lization; and monitoring and evaluation. One of
     the strategies for the objective related to reduction    The strategy estimates a total resource base of
     of unmet need for family planning is to “promote         $52.7 million for implementation over five years,
     reproductive health commodity security.” Howev-          slightly less than half of which would be allocated
     er, the objectives and strategies are not quantified     to commodities based on levels of unmet need.
     with specific targets for contraceptive prevalence,      Although the strategy does not assign resource al-
     stockout rate, or other indicators.                      locations among government and donors, it does
                                                              expect that the government contribution would
     A Strategy to Improve Reproductive Health in             increase from current levels. The Ministry is seek-
     Uganda, 2005 – 2010                                      ing technical assistance to develop a broader list of
     This strategy was published by the Reproduc-             costed commodities, a monitoring and evaluation
     tive Health Division of the MOH in 2004 to               framework and an implementation and workplan
     align with the period covered by the HSSP II.            for the strategy.
     The overarching goal of the strategy is to re-
     duce Uganda’s maternal mortality ratio to 408            National Family Planning Advocacy Strategy
     deaths per 100,000 live births by 2010 “through          2005 – 2010
     improved access to RH services, notably family           The objective of this strategy, produced by the
     planning and emergency obstetric care.” This goal        Reproductive Health Division of the Ministry
     is to be accomplished with improvements in the           of Health, is to reduce the high levels of unmet
     service provision of three areas: deliveries, family     need for family planning. The strategy highlights
     planning and antenatal care. In the area of family       relevant supportive policies (PEAP, National
     planning, the strategy aims to raise the contracep-      Population Policy, and HSSP II), but notes that
     tive prevalence rate (all methods) to 50 percent by      not much has been achieved in regards to their
     2010, with an unspecified “reduction in contra-          family planning and reproductive health goals.
     ceptive stockouts” as one of the projected outputs.      The advocacy recommendations include: public
     The MOH is identified as the lead national-level         leadership and support, access to information,
     agency for the strategy, with districts responsible      availability of commodities and supplies, ac-
     for program implementation.                              cess to services through integration, capacity for
                                                              service delivery, and education for young people
     Uganda Reproductive Health Commodities                   in school.
     Security Strategic Plan 2009 – 2014 (draft)
     The development of Uganda’s first contraceptive          National Advocacy Strategy in Support of
     security strategy was led by the MOH with finan-         Reproductive Health, Population and Develop-
     cial support from the United Nations Population          ment Programmes, 2005 – 2009
     Fund (UNFPA). The draft version of the strategy          The second major advocacy strategy, produced
     contains eight strategic objectives related to poli-     by the Population Secretariat with funding from
     cies, coordination, political and financial com-         UNFPA, aims “to guide implementation of
     mitment, financing, commodity security, demand           advocacy interventions targeting decision makers”
     and utilization of services, logistics, and monitor-     and “provides a framework for identifying key
     ing and evaluation. It specifies the assumptions         issues in reproductive health, gender, population
     and risks underlying its expected results, such          and development requiring actions on the part of
     as the assumption of continued and growing               policy makers.” The strategy identifies four focal
     financial resources and the risk of political rigidity   areas: high unmet need for family planning, high
     towards changing policies. Among the specific            infant and maternal mortality, resource shortfalls
     expected results of the strategy is a reduction in       and inadequate adolescent sexual reproductive
     the projected contraceptive financing gap, cur-          health services. Although one of the strategy’s
     rently estimated at 30 percent, to five percent by       goals is to ensure access to an “adequate variety of

family planning services,” it does not discuss re-    that its first drafts included no discussion of
productive health commodity security specifically,    family planning, but the current draft has three
nor are its goals quantified. The target audiences    central objectives: improve antenatal and obstetric
of the strategy range from the Ministry of Health     services, promote health seeking behavior, and
to local community leaders, but do not include        ensure family planning information and services
external development partners.                        are available. It is considered a tool for mobilizing
                                                      resources by including resource requirements and
Adolescent Health Policy, 2004                        broadening responsibility beyond the MOH and
Uganda’s Adolescent Health Policy was approved        donors. One of the key activities for the strategy’s
in 2004 after five years in draft form and ongoing    interventions will be to “support logistics manage-
advocacy efforts by interested NGOs.12 Although       ment for the right family planning commodities
the policy was not reviewed for this case study,      and supplies in the right times and right places.”
stakeholders report that it highlights the need to    Its targets include increasing the contraceptive
increase access to contraceptives among young         prevalence rate (CPR) (all methods) to 35 percent
people as a critical issue, along with adolescent     in 2010 and 50 percent in 2015; and to decrease
pregnancies, abortion and harmful traditional         unmet need for family planning to 20 percent in
practices.13                                          2010 and five percent in 2015.

National HIV & AIDS Strategic Plan                    The Roadmap was launched in 2008 but not yet
2007/8 – 2011/12                                      signed into law by the president, who has offered
The Uganda AIDS Commission produced this              suggested changes. According to a stakeholder
national plan to address the HIV/AIDS epidemic.       familiar with the process, President Museveni has
Prevention of transmission is one of the three        expressed concerns with the way the document
thematic areas of the plan, with a goal to reduce     addresses abortion.14 The MOH will be the lead
the incidence rate of HIV by 40 percent by 2012.      agency in implementation.
The promotion of the ABC+ approach (“Absti-
nence, Being faithful, and Condom use with risky      Condom Distribution Plan
sexual encounters, plus other strategies to reduce    The MOH has a Condom Coordination Unit
sexual risk”) covers the use of condoms. The          with a distribution plan designed to improve
integration of family planning services and HIV/      the supply chain for condoms between districts
AIDS service delivery is a strategy to combat the     and facilities. Like contraceptives, condoms are
high rate of mother-to-child HIV transmission.        integrated into the essential drugs credit line
The annex includes four indicators that track con-    and distributed by the National Medical Stores
dom use and availability, but the issue of ensuring   (NMS).15
condom supply security as a prevention strategy is
not addressed in the body of the plan.

Essential Drugs List of Uganda (EDLU), 2001
Three methods of hormonal contraceptives are
included on the EDLU: implants, injectables and
oral contraceptives. However, they are not includ-
ed on the national credit line of vital products.

Roadmap for Accelerating the Reduction of
Maternal and Neonatal Mortality and
Morbidity in Uganda, 2007 – 2015 (draft)
The Roadmap was developed by the MOH and
the World Health Organization (WHO) and also
supported by UNFPA. One stakeholder reported

         While the public sector health system allows for
         coordination and thorough examination of health
                                                                   lates the policies of the various health sectors in
                                                                   keeping with the goals and standards of national
         policies and programs at the central level, decentral-    policies. The HPAU evaluates proposed policies
         ization has given more decision-making power but          and advises sector leaders on policy changes.
         also created more challenges for Uganda’s districts.
         Standards and processes that are developed at the         Reproductive Health Division (RHD)
         national level in the Ministry of Health are some-        Housed in the Department of Community
         times unknown or ineffective by the time services         Health under the Directorate of Clinical and
         are rendered at the district level. There needs to be     Community Services, this division is responsible
         greater accountability on the part of both central-lev-   for advancing the reproductive health interven-
         el and district leaders to make sure national policies    tions outlined in the Uganda National Minimum
         translate to district outcomes.                           Health Care Package. RHD services include sex
                                                                   education, family planning, antenatal and obstet-
         CENTRAL LEVEL                                             ric care, and other efforts to ensure safe pregnancy
                                                                   and delivery. The RH Division chairs the RH
         Population Secretariat                                    Commodity Security coordination committee and
         Founded in 1988 and housed in the Ministry of             a Maternal and Child Health technical working
         Finance, Planning and Economic Development,               group tied to the HSSP.
         the Population Secretariat is a semi-autonomous
         government body tasked with coordinating the              National Drug Authority (NDA)
         implementation of the country’s population poli-          The National Drug Authority is the regulatory
         cies across sectors at the central and district levels.   body for all medicines. It ensures the quality,
         The agency advises the government on demo-                safety, and efficacy of the drugs that are made
         graphic trends and advocates for the inclusion of         available to the public. Commodities must be
         population issues in policies, programs, strategies       registered with the NDA prior to distribution in
         and resource allocation. The Secretariat also pro-        Uganda. The NDA inspects all health commodi-
         duces an annual report titled The State of Uganda         ties before they are sent to various warehouses
         Population, with support from UNFPA.                      to be prepared for distribution. The inspection
                                                                   process includes the testing of imported condoms
         Ministry of Health (MOH)                                  (except from the U.S. Agency for International
         The objective of the MOH is to establish poli-            Development) by a modern condom-testing unit
         cies and standards for health care delivery at all        to prevent expired condoms from being shipped
         levels of the health care system. Its core functions      to National Medical Stores.
         include policy formation, resource mobilization,
         and monitoring and evaluation of health sector            National Medical Stores (NMS) and Joint
         performance. The MOH coordinates stakehold-               Medical Stores (JMS)
         ers, research activities, professional training and       The National Medical Stores is an autonomous
         employment processes to ensure the smooth                 body of the MOH whose purpose is to pro-
         operation and integrity of health care services.          vide the country with affordable, good quality
                                                                   pharmaceutical products. NMS is responsible
         Health Policy Analysis Unit (HPAU)                        for the procurement, storage, administration,
         The Health Policy Analysis Unit of the MOH is             and distribution of drugs, medical supplies and
         the highest decision-making body on health care           equipment. It is charged with maintaining the
         policy. This unit researches, analyzes, and formu-        level of drug and service quality mandated in the

                                                                                                               Supplies await distribution
                                                                                                               at the National Medical
                                                                                                               (Susan Anderson/PAI)

National Drug Policy. The NMS manages the             implementing health services, including family
distribution of all contraceptives, including those   planning and reproductive health, using funds
procured independently by donors, to lower levels     transferred to them by central level, which may or
of the health system.                                 may not arrive on time or in full.16

JMS is a parallel, equivalent agency to NMS           There are 81 districts, each with two to eight
which provides drug distribution services to faith-   health sub-districts. Each health sub-district
based and NGO health providers. Due to its link       has approximately ten health facilities under its
to the Catholic Church, it does not procure or        jurisdiction. These sub-district health facilities are
distribute contraceptives and condoms.                instrumental in increasing access to health services
                                                      at the lowest levels. A district population officer
Uganda AIDS Commission (UAC)                          has been established in all districts to incorporate
Established in 1992, the Uganda AIDS Com-             population issues into district plans, working with
mission coordinates responses to the HIV/AIDS         economists and statisticians.
epidemic. The UAC is responsible for formulat-
ing policy and mobilizing resources for the AIDS      At the community level, members of village
control program. The UAC does not implement           health teams, who make home visits, can provide
programs; rather, it leads AIDS research and advo-    pills, condoms and, in practice, injectables. The
cacy efforts and is instrumental in promoting the     provision of injectables by village health team
use of condoms and other forms of contraception       workers was tested in pilot projects implemented
that can prevent the transmission of HIV.             by the MOH, Family Health International and
                                                      other partners, though this method is not yet
District Health Services                              reflected in official policy. Clients are referred to
Uganda’s health services, as well as other author-    Level III health centers at the sub-district level for
ity and responsibilities, were decentralized to the   implants and IUDs (injectables are also available),
district level through the Local Government Act       and to Level IV centers at county level for perma-
of 1997. Each district develops a District Health     nent methods, which are provided by doctors.
Sector Strategic Plan that feeds into the district
development plan. Districts are responsible for

         It is difficult to determine spending on reproductive
         health broadly in Uganda due to the decentralized
                                                                  to health. This percentage decreased to 9.0 in
                                                                  FY 2005/06 and further still to 8.3 percent in
         nature of the budget. Figures on spending for contra-    FY 2007/08.20 According to a MOH official, the
         ceptives and condoms are somewhat more clear, but        government contribution to health rose to 9.8
         disbursement lags significantly behind allocations for   percent of the total budget in 2008/09. Despite
         health in general and reproductive health supplies       the recent upward movement, this trend suggests
         specifically in the public sector. Contraceptives are    a need for continued strong donor support. From
         still largely funded through off-budget vertical sup-    2005 to 2007, Uganda was among the top ten
         port from donors.                                        country recipients of donor support for contra-
                                                                  ceptives and condoms.21
                                                                  Uganda’s Medium Term Expenditure Framework
         Government of Uganda (GOU)                               sets strict budget ceilings that limit the funding
         Financing of the health sector in the budget of          that can be allocated to any sector. The budget
         the government of Uganda is drawn from a mix             ceilings were implemented in part to encour-
         of sector support and the Poverty Action Fund            age greater country ownership and to create a
         (PAF). The PAF is a general budget support               balanced budget. But as a result, funds that are
         fund that pools resources to support the imple-          channeled through the health sector and the
         mentation of the Poverty Eradication Action              Poverty Action Fund compete with funds sup-
         Plan. These funds are targeted to both central           plied through global initiatives, such as the Global
         and district levels, with districts developing their     Fund to Fight AIDS, Tuberculosis and Malaria
         own health sector plans in line with the HSSP            (GFATM) and the Global Alliance for Vaccines
         II. Government-supported contraceptives and              and Immunization (GAVI).22 The result is that
         condoms are funded through a PAF budget line             the presence of external disease-specific funding
         item and are provided free of charge to districts.       can be detrimental and reduce the amount of
         In addition, some donors maintain dedicated ver-         internally generated funds for other health issues.
         tical funding off-budget; this modality provides a
         majority of the funding for RH supplies.                 Joint Assistance Framework
                                                                  A new Joint Assistance Framework (JAF) guid-
         The GOU has cited increasing program funding             ing donor contributions to the priority develop-
         from donors and the need to increase funding in          ment areas of Uganda’s government began in the
         other sectors as reasons for lowered government          2008/09 fiscal year. With a focus on performance
         health support.17 Government support for health          and results, the government and its development
         remains minimal; “between 50 and 70 percent of           partners agreed to include CPR as an indicator to
         the MOH budget for drugs and services is pro-            measure the success of the framework. However,
         vided by donor organizations.”18 For the health          the agreed target for CPR among married women
         sector as a whole, supplies of medicines are less        is a relatively unambitious 30 percent, including
         than half of required amounts.19                         traditional methods, a level that currently stands
                                                                  at 24 percent as measured by the DHS. Progress
         Currently, there are no indications that govern-         towards the CPR target will be measured annually
         ment health spending will increase. In fact, data        by the Uganda Bureau of Statistics (UBOS) with
         on health expenditures show a recent decrease in         technical and financial support from UNFPA.23
         GOU support. In fiscal year (FY) 2004/05, the
         GOU devoted 9.7 percent of the national budget

Government support for health remains minimal;
“between 50 and 70 percent of the MOH budget
for drugs and services is provided by donor

Sector-Wide Approach (SWAp)                            tor Strategic Plan. However, a drawback of the
In 2000, the SWAp was introduced in Uganda as          SWAp is that donor funds that previously were
a way to improve coordination between the gov-         earmarked for contraceptives and other reproduc-
ernment and development partners. The donors           tive health supplies are now pooled in one fund
who signed the Memorandum of Understanding             to support the general budget, and the amount of
(MOU) that enacted the SWAp are: the bilateral         funding that is allocated to contraceptives is not
governments of Austria, Belgium, Denmark,              guaranteed.
France, Germany, Ireland, Italy, Japan, the Neth-
erlands, Norway, Sweden, the United Kingdom            Direct Donor Funding to Vertical Programs
and the United States; the African Development         As in other countries, many donors in Uganda
Bank, the European Union, the United Nations,          have shifted to sector and general budget support,
the World Bank, and the World Health Orga-             but others continue to provide direct funding to
nization. All donor funding is overseen by the         vertical programs. This funding modality remains
Ministry of Finance and Economic Development,          the mainstay for the U.S. Agency for Interna-
which then allocates money to each sector. The         tional Development (USAID), which is unlikely
government and SWAp donors meet regularly              to shift to country-driven mechanisms given
to coordinate health sector policies through the       concerns about accountability and transparency
Health Policy Advisory Committee and annual            of government spending, as well as for UNFPA.
Joint Review Mission, while donors also meet in        Direct contraceptive funding from UNFPA and
the Health Development Partners Group.                 USAID represents approximately two-thirds of
                                                       the total public sector budget for contraceptives.25
The successful funding of the SWAp is critical to      The government of Uganda is reportedly negoti-
the realization of the Health Sector Strategic Plan.   ating a financing arrangement from the African
In its early years, the Uganda SWAp had been           Development Bank that would in part support
widely cited as an example of a successful financ-     reproductive health.26
ing modality. In the Memorandum of Under-
standing for implementation of the HSSP II, the        Global Initiatives
government has stated that its preferred funding       The emergence of global health partnerships
mechanism is direct budget support.24 Upon the         and initiatives such as GFATM, GAVI and the
signing of the MOU, the GOU took seriously its         President’s Emergency Program for AIDS Relief
commitment to increase health spending and do-         (PEPFAR) is another factor in the shift from bud-
nors strove to provide budget support as opposed       get support to disease-specific program funding.
to program support. These efforts led to success       These global funds place emphasis on health in-
in reaching targets set out in the first Health Sec-   terventions that advance progress on the MDGs,

A poster promotes family
planning for family welfare.
(Jennifer Johnson/PAI)

                               and donors are drawn to their targeted programs.        for medicines was spent on contraceptives.33
                               The vast majority of donor support for HIV/             Since FY 2005/06, the Ugandan government
                               AIDS in Uganda is provided by PEPFAR.27                 has allocated approximately 1.5 billion Ugandan
                                                                                       shillings (US$700,000) annually for reproduc-
                               Uganda has not maintained consistent funding            tive health commodities.34 However, spending of
                               from the GFATM due to the Fund’s concerns               the contraceptive line item has been low, with as
                               about mismanagement.28 After corruption issues          few as two to six percent of the allocated funds
                               prevented a Round 8 bid, the committee manag-           disbursed. According to one government of-
                               ing GFATM applications was disbanded and is             ficial, the 2008/09 contraceptive allocation was
                               currently being reformed.29                             reprogrammed to immunization after GAVI
                                                                                       withdrew funding from Uganda due to corrup-
                               Contraceptive Financing and Coordination                tion concerns. The MOH prioritizes procurement
                               Tracking funding for reproductive health is dif-        of condoms, injectables, oral contraceptives and
                               ficult given the decentralization of service delivery   emergency contraception.
                               and budgeting as well as the shift toward health
                               service integration. According to an official in        Total contraceptive funding from USAID is
                               the Ministry of Health, five percent of the health      approximately $3 million annually, excluding
                               sector budget is targeted to reproductive health;       condoms funded by PEPFAR, which account
                               another source reports a much higher ratio of 19        for another $2 million. USAID procurement,
                               percent.30 The funds are sourced roughly equally        which has been dedicated to condoms, implants,
                               from donors and government contributions from           injectables, IUDs and oral contraceptives, occurs
                               the Poverty Action Fund.31                              through a central mechanism managed in Wash-
                                                                                       ington. UNFPA provides condoms, implants,
                               Approximately 14 percent of the contracep-              injectables, IUDs and oral contraceptives.35 Table
                               tive need in Uganda is covered by government            2 highlights the value of contraceptive shipments
                               financing, including funds drawn from sector            to Uganda from 2004 to 2008.
                               and budget support.32 The budget line item
                               for contraceptives is supported by the PAF. In          The Ministry of Health has identified a 30
                               2007/08, 0.7 percent of the government budget           percent gap between contraceptive need and avail-


 Source                       2004                     2005                  2006                 2007          2008

 USAID                      4,957,063             4,490,535               3,487,513            3,214,432      3,678,226

 UNFPA                        255,449                 1,169,748             493,107              799,914      1,766,549

 IPPF                            8,134                  15,326               10,370                11,483        9,383

 KfW                                                                        164,088              164,278       192,017

 Other                                                                                                         112,292

 Total                     $5,220,647            $5,675,605              $4,155,078           $4,190,108     $5,758,467

able funding. In light of the uncertain status of        At lower levels, each district has a Drug and
contraceptive financing and unstable government          Therapeutics Committee (DTC) that is designed
spending on health, the existence of a Repro-            to coordinate procurement and distribution of all
ductive Health Commodity Security (RHCS)                 pharmaceuticals. Each district also has a popula-
coordination committee plays an important role           tion officer and a RH focal person.37
guiding the future of RH supplies financing and
coordination. The RHCS coordination commit-              Linkages with HIV and AIDS Funding
tee is chaired by the Reproductive Health Divi-          Family planning and reproductive health are
sion of the MOH and members include National             rarely tied to HIV/AIDS other than through
Medical Stores, the Population Secretariat, the          condoms, a dual protection method. Stakeholders
UK Department for International Development              report that the government counts external HIV/
(DFID), the USAID | DELIVER Project, UN-                 AIDS contributions against the health sector bud-
FPA, USAID, social marketing entities, and other         get, leaving only a small amount of pooled and
important NGOs. This group maintains a stance            internally generated funding to support the wide
of zero tolerance for contraceptive stockouts. The       range of other health programs. HIV and family
committee recently commissioned a situation              planning have been kept parallel and separate,
analysis that identified six priority areas and fed      with political commitment from the government
into the development of the draft Contraceptive          and donors often focused on HIV/AIDS.
Security Strategy.
                                                         Due to the mismanagement of HIV/AIDS
Another coordination body is the Family Plan-            funding, it is unclear whether efforts to improve
ning Revitalization Working Group, started in ap-        contraceptive security will benefit from integra-
proximately 2004 by the Ministry of Health and           tive HIV/AIDS/FP services.38 The government
USAID. It is chaired by the MOH and intended             of Uganda deferred submitting a proposal with a
to expand the mix of available RH supplies. The          large component of integrating family planning
Working Group has been meeting irregularly,              with HIV/AIDS activities for round 8 of funding
with most recent meetings in June 2008 and               from the GFATM.
March 2009.

         At the 2007 meeting of the Eastern Africa Reproduc-
         tive Health Network, RH advocates identified the
                                                                   tives.40 Still, NMS at central level is not immune
                                                                   from shortages of supplies. In late February 2009,
         uneven distribution system below district level and       NMS was stocked out of one brand of implants
         weak demand and utilization of RH supplies as             and had an inventory of less than two weeks sup-
         main challenges in Uganda. Stockouts of RH sup-           ply of Microgynon, an oral contraceptive, with
         plies are widely described as common. Although there      the next shipment not expected until two months
         is an integrated distribution system, the government      later. The stock levels of four other methods
         relies on external technical assistance for forecasting   (condoms, a second brand of implants, IUDs and
         and the logistics data used for long-term planning        a second brand of oral contraceptives) were lower
         are poorly maintained by facilities and unreliable.       than the recommended six months’ supply.41
         Logistics and procurement problems are more detri-
         mental to the availability of RH supplies in Uganda       Uganda’s health system is supplemented by faith-
         than any limitations on funding.                          based facilities, which help fill the gap in the
                                                                   provision of services. This does not always apply
         Technical capacity of bureaucrats varies, with            in the case of RH supplies, however. If NMS is
         some describing the knowledge base on repro-              unable to provide commodities, districts can turn
         ductive health in the MOH as outdated. At the             to the alternative Joint Medical Stores that sup-
         facility level, institutional capacity needs great        plies Catholic facilities. However, JMS does not
         improvement, and MOH supervision is limited.              provide contraceptives. In addition, some district
         As in many countries, there are too few health            drug orders are managed by individuals who will
         workers; in Uganda, many stakeholders report a            not push facility orders for contraceptives further
         low level of motivation among staff and a lack of         up the supply chain due to their religious beliefs.42
         passion to push for change. When orders don’t ar-
         rive on time, district officials may lack the time to     Forecasting
         track order status and follow up with the NMS.            Annual forecasting for contraceptives occurs at
         Given the scale of these logistical problems, it          the central level, led by the RHCS coordination
         can be easy to overlook that contraceptives are           committee, which meets quarterly to review stock
         essential medicines.                                      levels and financial commitments. Contraceptive
                                                                   procurement tables (CPTs) for the forthcom-
         Stock quantities at central level are generally           ing three years are prepared by the MOH with
         considered adequate, but there is a breakdown in          technical assistance from the USAID | DELIVER
         the distribution system between central and facil-        Project. The annual CPTs are used by MOH and
         ity level. Reproductive health supplies are listed        donors to set funding commitments, which in
         at the end of the credit line order forms filled out      turn determines annual contraceptive procure-
         by facilities. Because they are provided on a “third      ment.
         party” basis, there is no cost to districts to order
         them but also no financial benefit to National            Procurement
         Medical Stores for supplying them. According              The MOH and its major donors of RH supplies,
         to one stakeholder, such “third party” drugs are          USAID and UNFPA, each handle their own pro-
         loaded last onto delivery trucks.39 A government          curement of contraceptives. UNFPA also offers a
         official reported that poor management of stock           pooled procurement service in which government
         recently forced NMS to destroy expired com-               and international agencies can have access to the
         modities worth 800 million shillings ($375,000),          Fund’s volume discounted pricing in exchange
         of which roughly one-quarter were contracep-              for an administrative fee. USAID and UNFPA

together procure almost two-thirds of Uganda’s         Storage and Distribution
contraceptives.43 Unfortunately, donor coordina-       Formerly separate from essential drugs, contracep-
tion related to the delivery of commodities is         tives procured for the MOH are now a part of the
still weak. While the MOH knows the quantity           essential drug distribution system. Contraceptives
of contraceptives and condoms that need to be          for the public sector are managed in a pull system,
procured, the MOH is not always sure how much          with sub-district level health facilities responsible
donors plan to commit towards the fulfillment          for ordering contraceptives. There is a monthly
of the requirements set out in the CPTs, and the       stock review at the national level.
timing of shipments is ad hoc.44
                                                       A 2006 survey found that the distribution of
Various challenges inhibit smooth procurement          contraceptives to MOH facilities surpassed that of
on the part of the National Medical Stores.            NGO facilities with 80 percent of MOH facilities
Government funds are released quarterly, with          having contraceptives in stock on the day of visit
none available for contraceptives and certain other    compared to 60 percent of NGO facilities. Con-
non-emergency drugs in the first quarter until the     doms were in stock in two-thirds of both MOH
annual budget is approved. The MOH typically           and NGO facilities.49 This is promising given
makes a single large annual procurement in order       recent widespread limited condom availability due
to take advantage of volume pricing discounts.45       in part to condoms getting stuck at district levels.
However, these delays in the release of funds          Annual tracking of the availability of essential
reverberate throughout the system, as NMS is un-       drugs includes Depo-Provera (injectable contra-
able to process order requests from facilities until   ceptive) as a tracer drug; its availability has varied
funds are available. Other major problems include      widely in recent years, with 16 percent of facilities
“limited human and infrastructural capacity avail-     reporting a monthly stockout in 2006/07.50
able at NMS as well as inadequate delegation of
authority and poor allocation of funds to…NMS          Many stakeholders report that stockouts of RH
by government.”46 Together, these challenges cre-      supplies are frequent, but primarily affect facili-
ate a situation in which “the MOH is extremely         ties. Although there are sufficient quantities at
dependent on third-party procurement and when          central level, one government official identified
this procurement fails or is delayed, the result is    weaknesses in NMS that prevent supplies from
major product stockouts.”47                            effectively reaching service delivery points. These
                                                       weaknesses include poor management, lack of
The transference of logistics information between      long-term forecasting, and various transport is-
NMS, districts and lower levels is spotty. Health      sues, including too few vehicles and inadequate
facilities use integrated Health Management            maintenance. While funding challenges remain,
Information System (HMIS) forms to monitor             health systems strengthening is more critical, ac-
consumption data. However, quantities of physi-        cording to many observers.
cal and recorded stock are often mismatched, and
monthly consumption data reported from facili-
ties to higher levels is often inaccurate.48

         The government relies heavily on its two major
         donors and their partners for financial and technical
                                                                  Essential Drugs List. The agency also drafted the
                                                                  new Roadmap to reduce maternal mortality. In
         assistance. Many NGOs carry out work related to          the past, the WHO provided condoms through
         reproductive health and supplies and have moderate       the Multisectoral AIDS Program.52
         capacity, but their efforts are hampered by an unen-
         thusiastic response from government officials, whose     BILATERAL AGENCIES
         attention may be diverted by other health issues or
         who feel fatigue about reproductive health issues. The   Danish International Development Agency
         most promising champions for reproductive health         (DANIDA)
         supplies currently may be parliamentarians, whose        The Danish International Development Agency
         support is mingled with a certain degree of budgetary    (DANIDA) has been active in Uganda since 1986
         authority. Still, stakeholders agree that new champi-    and directs the vast majority of its sector and bud-
         ons are desperately needed.                              get support through the National Health Policy,
                                                                  with a small amount provided to hospitals. It has
         MULTILATERAL AGENCIES                                    historically funded a large share of the National
                                                                  Medical Stores budget for drugs, and has also pro-
         United Nations Population Fund (UNFPA)                   vided training and capacity-building to NMS. Its
         UNFPA has collaborated with the government of            only vertical program support to the health sector
         Uganda since 1987 and has been instrumental in           is targeted to HIV/AIDS.
         the operation of maternal and child health and
         family planning programs. UNFPA funds training           Department for International Development
         for reproductive health and family planning ser-         (DFID)
         vices, and is one of two donors of contraceptives        The Department for International Development
         (other than condoms) in Uganda. UNFPA pro-               (DFID) is the United Kingdom’s international aid
         vides a range of technical support services, funds       agency. Its main funding purpose in Uganda is to
         a RHCS coordination position in the MOH, and             support the implementation of the Poverty Eradi-
         has facilitated the development of advocacy poli-        cation Action Plan (PEAP). Thus, it provides
         cies related to FP/RH and the new contraceptive          budget support for the government of Uganda to
         security strategy.                                       use at its discretion. DFID has also funded PSI
         World Bank
         From 2001 to 2006, the World Bank procured               German Development Bank (KfW)
         condoms for the MOH, through its Multi-Coun-             KfW is a German development bank that has
         try HIV/AIDS Program for Africa. The Bank                historically provided funding to Marie Stopes In-
         provided up to 80 million condoms for the public         ternational for LifeGuard condoms, although this
         sector, which is the bulk of the average yearly          is ending, as well as general budget support to the
         requirement of 120 million condoms. During               Ugandan government. Programs funded include
         a four-year collaboration period with USAID |            Healthy Life vouchers which allow Ugandans
         DELIVER, the World Bank provided 160 million             from poor communities to receive STI treatment
         condoms to the MOH.51                                    services.

         World Health Organization (WHO)                          U.S. Agency for International Development
         The World Health Organization has served as a            (USAID)
         policy advisor, especially in the formation of the       USAID has been a longtime supporter of family

The private sector provides the majority of
contraceptives, accounting for 65 percent
of the market.

planning activities in Uganda. It is the largest      FPAU was officially recognized by the government
donor of contraceptives and manages the activi-       and registered as a non-governmental organiza-
ties of multiple cooperating agencies (see below).    tion in 1963, and became a member of IPPF the
Currently, it funds the AFFORD social marketing       following year. The organization changed its name
program, which markets contraceptives, condoms        to Reproductive Health Uganda in 2007 to reflect
and MoonBeads, a traditional family planning          a focus on providing comprehensive reproductive
product, and in 2009 is beginning a new five-year     health care.
project on family planning service delivery. In
the past, USAID funded the activities of PSI in       For the past fifty years, RHU has worked to
addition to several projects including the Delivery   empower women, reduce unsafe abortion, meet
of Improved Services for Health (DISH) and the        needs for family planning, increase access to
Community Reproductive Health Project. Ac-            youth sexual and reproductive health services
cording to a DELIVER report, USAID contri-            and increase advocacy for reproductive health.
butions for the purchase of contraceptives may        Complementing government family planning
decrease as UNFPA funding increases.                  services, RHU helps to expand access underserved
                                                      populations. Services are delivered in 23 clinics,
CIVIL SOCIETY/NGOs                                    each operated by registered midwives. In addition
                                                      to the staff at the clinics, RHU has a network of
The private sector provides the majority of contra-   260 community-based distribution agents. The
ceptives, accounting for 65 percent of the market.    agents are trained to provide services to continu-
The bulk of this share is from the private medical    ing and new family planning acceptors. Through
sector. The remaining 35 percent market share         Project RMA, RHU is actively involved in RH
of RH supplies is covered by the public sector.54     supplies advocacy in Uganda, including engage-
Civil society has an important role to play in        ment with the media, awareness-raising at district
improving availability and access to RH supplies      level and participation in the development of new
among government and other sources.                   policies and strategies.

Reproductive Health Uganda (RHU)                      Marie Stopes International (MSI)/Marie Stopes
Formerly named the Family Planning Association        Uganda (MSU)
of Uganda (FPAU), RHU is the International            Marie Stopes Uganda and the Uganda country of-
Planned Parenthood Federation (IPPF) member           fice of Marie Stopes International operate separate
association in Uganda. Its mission is to ensure       activities in Uganda as two different organizations
universal access to sexual and reproductive health.   under the Marie Stopes umbrella. Marie Stopes
Established in 1957, RHU was the pioneer in           International focuses on social marketing of Life-
providing family planning services in Uganda.         Guard condoms for HIV/AIDS prevention, while

     MSU maintains 16 clinics offering RH supplies          planning in order to advance the goals set at
     in addition to mobile clinics and outreach teams       the ICPD in 1994. PPD launched the Eastern
     that cover 85 percent of the country’s districts.      Africa Reproductive Health Network (EARHN),
     MSU implements the Reproductive Health Ac-             which is headquartered in Uganda. At a meet-
     cess, Information and Services in Emergencies          ing organized by EARHN in August 2008,
     (RAISE) Initiative to provide access to sexual and     Members of Parliament from member countries,
     reproductive health services in emergency settings,    including Uganda, agreed to address the need for
     including camps for internally displaced persons       reproductive health supplies and increase health
     (IDPs) in Uganda. MSI’s Life Guard condoms             sector funding. In 2009, EARHN will focus on
     comprise a majority of the condom market but           strengthening advocacy and increasing financing
     their longtime funder, KfW, has withdrawn its          for reproductive health supplies.
     support to focus on other sectors, and as of March
     2009, the condoms were likely to be stocked out        Population Services International (PSI)
     within four months. Two of MSU’s other donors,         In 1998, Population Services International began
     DFID and the European Commission, are also             work in Uganda, and PSI/Uganda was established
     phasing out their contributions.                       in 2003. PSI/Uganda works with the MOH and
                                                            community-based organizations to disseminate
     In late 2008, Ugandan First Lady Janet Museveni        health services to rural populations, with some
     stated in a public speech that a U.S. government       activities funded by DFID. PSI/Uganda sup-
     official had informed her that MSU was providing       ports social marketing and has marketed the Trust
     illegal abortion services in various countries, in-    condom brand since 2006. Through funding
     cluding Uganda. At approximately the same time,        from UNFPA, PSI is supporting the MOH in the
     the U.S. government issued a directive banning         development of a female condom programming
     the provision of any contraceptives funded by          strategy for Uganda.
     USAID from being directed to national affiliates
     of MSI, which seriously disrupted MSI’s services       Uganda Private Midwives Organization
     in six African countries, including Uganda. Be-        (UPMO)
     cause all contraceptives in the country are distrib-   Formerly the Uganda Private Midwives Associa-
     uted through the National Medical Stores, fears of     tion, the UPMO is a network of approximately
     accidentally directing a USAID-funded shipment         2000 midwives. In their private practices, mid-
     of supplies to MSI essentially froze the distribu-     wives provide reproductive health, HIV/AIDS/
     tion of any supplies to the agency for months. In      PMTCT (prevention of mother to child trans-
     March 2009, two months after the Mexico City           mission) and primary health care services. The
     Policy/Global Gag Rule was overturned, USAID           midwives work to supplement the services offered
     officially rescinded the ban targeting MSI.            by the Ministry of Health, operating according to
                                                            the MOH Midwifery Standards. UPMO’s many
     Partners in Population and Development                 outreach activities are funded by its partners,
     (PPD) and the Eastern Africa Reproductive              including USAID, UNFPA and EngenderHealth.
     Health Network (EARHN)
     Partners in Population and Development is a            Uganda Reproductive Health Advocacy
     22-member initiative aimed at addressing sexual        Network (URHAN)
     and reproductive health and rights in developing       URHAN was formed in 2006 as a loose network
     countries. PPD focuses on improving South-             of organizations working on reproductive health
     South collaboration on issues such as family           and was originally funded by the Futures Group.

Its work has focused on youth-friendly services,      district levels, obstetric fistula and strengthening
including advocating for the publication of the       the integration of family planning and HIV/AIDS
Adolescent Health Policy, and now for its effective   prevention programs. Currently, EngenderHealth
implementation. URHAN currently relies on the         is implementing a five-year project on fistula in
volunteered time and contributions of its mem-        10 countries, including Uganda, and continuing
bers and is not externally funded.                    the family planning revitalization efforts in four
Of the 102 female members of Uganda’s parlia-         Family Health International (FHI)
ment, 40 are active in a network supporting ma-       FHI implements the Contraceptive and Repro-
ternal health. The network, whose members are         ductive Health Technologies Research and Uti-
often described as among the most vocal cham-         lization (CRTU) project in five focus countries,
pions of reproductive health in the country, has      including Uganda. The project’s work to improve
worked with other organizations such as RHU to        access to existing contraceptives, especially long-
promote family planning at the district level. The    term methods, has included advocacy with the
network is also currently advocating for a budget     MOH to allow community health workers to
line item for reproductive health within the health   dispense injectables. FHI also provides training
sector budget. Another related lobby group of         and capacity-building for FP/HIV integration.
parliamentarians is the Forum on Food Security,
Population and Development, whose members             Futures Group
receive training from the Population Secretariat.     The Futures Group is one of the five organiza-
                                                      tions working with CCP to implement the
USAID COOPERATING AGENCIES                            AFFORD project. Through the POLICY Poject,
                                                      in previous years the Futures Group implemented
Center for Communications Programs                    advocacy activities to strengthen the policy envi-
The Center for Communications Programs at the         ronment for reproductive health, raised awareness
Johns Hopkins University Bloomberg School of          of the connections between population and other
Public Health leads AFFORD, a social marketing        development issues and collaborated with the
program funded by USAID. Its goal is to provide       Population Secretariat and district officials.
affordable health products and services in a wide
range of areas, including HIV/AIDS and malaria.       John Snow, Inc. (JSI)
In 2008, AFFORD launched the Uganda Health            Since 2001, JSI has implemented the USAID |
Marketing Group (UHMG) to market a wide               DELIVER Project, which provides technical as-
range of reproductive health supplies, including      sistance to Uganda in the area of logistics systems,
oral contraceptives, injectables, condoms, STI        working to improve the delivery of health services
treatments and a traditional family planning          for family planning, HIV/AIDS, tuberculosis and
method.                                               essential drugs. The DELIVER Project also pro-
                                                      vides technical assistance in the development of
EngenderHealth                                        CPTs and contraceptive forecasting information.
EngenderHealth has been working in Uganda for
over 20 years. It served as the lead implementing     Management Sciences for Health (MSH)
agency on the ACQUIRE Project, which ended            MSH is the lead implementing partner on
in late 2008. In Uganda, ACQUIRE focused on           USAID’s new major family planning, repro-
family planning revitalization at the national and    ductive health and child health service delivery

A family planning poster
on display at the Ministry
of Health.
(Elizabeth Leahy/PAI)

                             project in Uganda, unnamed as of March 2009.          improved water sources in eight districts in the
                             The project will work for five years to bridge pro-   northern region. USAID has funded Pathfinder
                             gramming at the central and district level, with 15   projects to provide services to orphans and other
                             focus districts.                                      children affected by HIV/AIDS, and other proj-
                                                                                   ects have been supported by UNFPA. In general,
                             Pathfinder International                              Pathfinder focuses on the conflict-affected regions
                             Pathfinder has been working in Uganda since           of the north, where access to RH supplies is also
                             the 1950s, when it was instrumental in forming        especially limited, and has a number of programs
                             the country’s family planning program. Its work       targeting youth on issues such as unsafe abortion
                             currently includes the Community-Based Fam-           and capacity-building.
                             ily Planning Project, funded by an anonymous
                             donor to train health workers, raise awareness
                             among community leaders about family planning
                             and equip health centers with RH supplies and

In addition to some specific issues identified in
the above sections, the following advocacy entry
                                                      have achieved results, but motivation throughout
                                                      the health system is lacking, except for HIV,” one
points were gleaned from discussions with stake-      stakeholder reports. If no one holds the govern-
holders in Uganda, and are based on recommen-         ment accountable now, the chances for achieving
dations for future advocacy around RH supplies        a high-quality reproductive health program in the
that were solicited in interviews. However, these     future diminish.
entry points should not be considered to prescribe
or in any way direct the strategies and plans for     Even though unmet need for family planning in
advocacy devised by civil society organizations       Uganda is among the highest rates in the world,
and others in Uganda.                                 few clients are pressuring the government for ac-
                                                      cess to contraceptives. “If you’re not used to a ser-
Project RMA has identified four indicators by         vice, you don’t ask for it,” one official explained.
which to assess national readiness in contraceptive   Another said that “people need to know it is their
security. These are:                                  right to receive the services; it is not a favor.”
                                                      Grassroots advocacy is uncommon in Uganda,
n the existence of a contraceptive supply coordina-   and according to a recent situation analysis, “civil
  tion mechanism;                                     society is not empowered enough for RH com-
n the inclusion of contraceptives on the national     modity security advocacy.”55 While parliamentar-
  essential drug list;                                ians are widely cited as the most prominent and
n a government budget line item for contraceptive     dedicated proponents of reproductive health in
  supplies; and                                       Uganda, some stakeholders note that they cannot
n the integration of contraceptive supplies into a    carry an entire advocacy agenda alone. “We need
  financing mechanism.                                new faces,” one observer explained.

Uganda is an interesting case because of the con-     Opinions differ on whether to focus efforts on
trast between policies supporting family planning     awareness-raising, gender and cultural issues
and reproductive health and high level disinter-      and generating demand for RH services, or on
est and sometimes, disapproval, of these issues.      strengthening the weak systems that impede de-
Advocates for RH supplies must be able to shape       livery of such services. Commenting on Uganda’s
public opinion by successfully touting the benefits   high rate of unmet need, one stakeholder said
of family planning and the cultural acceptability     “Advocacy without services is getting us nowhere.
of smaller family sizes. Although unmet need          As we rally communities, we must empower
for family planning is extremely high, it is rarely   them around working systems.” However, others
vocalized, and only when demand is clearly            express concern with the way that family planning
articulated by communities will RH supplies be        is “packaged.” In Uganda, children are revered for
prioritized by MOH officials as important health      various cultural reasons, and promoting smaller
commodities.                                          family size as a stand-alone message counters
                                                      certain important social norms and can therefore
Stakeholders generally agree that financial re-       be ineffective. Instead, linking access to RH sup-
sources are not the main constraint on improving      plies as part of a broader framework with other
access to RH supplies in Uganda. “With all the        issues, such as health and human rights, may have
money we’ve had over the past years, we should        greater resonance.

          1 The existence of a contraceptive supply            for coordination of only RH supplies at district
            coordination mechanism                             level. The contraceptive security assessment
                                                               recommends that DTCs begin holding designated
          There is a Reproductive Health Commodity             meetings for coordination of RH supplies, chaired
          Security (RHCS) coordinating committee operat-       by district health officers with ongoing implemen-
          ing in Uganda with representation from govern-       tation by district RH focal persons.56
          ment agencies, donors and NGOs. However, the
          RHCS working group is still developing a policy      2 The inclusion of contraceptives on the
          on contraceptive security. The draft strategy          national essential drug list
          includes ambitious results and a quantification
          of resource needs, but does not delineate fund-      Three hormonal methods of contraceptives are
          ing responsibilities among the government and        included on the Essential Drugs List of Uganda:
          its development partners. In order to promote        oral contraceptives, injectables and implants. To
          government accountability for financing contra-      help ensure that procurement of contraceptives
          ceptives and other reproductive health supplies,     will meet increasing demand, the list should be
          the RHCS coordination committee should lead          expanded to include the full range of commodi-
          the development of a financial sustainability plan   ties on the World Health Organization’s inter-
          for contraceptives.                                  agency list of essential medicines for reproductive
          Stockouts occur regularly, but the stock level of
          supplies at central level is widely described as     3 A government budget line item for
          adequate, and the process clearly breaks down at       contraceptive supplies
          lower levels. Given decentralization in Uganda,
          district leaders may be best-positioned to press     In accordance with the National Health Policy,
          National Medical Stores on delivery issues. A        which states that the “government shall continue
          recent contraceptive security assessment recom-      to allocate and spend an increasing propor-
          mends that the RHCS coordination committee           tion of its annual health budget (both domestic
          initiate regular meetings with district Drugs        and external resources) for the provision of the
          and Therapeutic Committees to formalize RH           [minimum health care] package,” there is an
          supplies coordination between central and lower      MOH budget line for contraceptives. As fam-
          levels. Currently, there is no formal mechanism      ily planning is an important component of the

Opinions differ on whether to focus efforts on
awareness-raising, gender and cultural issues
and generating demand for RH services, or on
strengthening the broken systems that impede
delivery of such services.
                                                                                                              Patients wait at a rural
                                                                                                              health clinic outside
                                                                                                              (Elizabeth Leahy/PAI)

Uganda National Minimum Health Care Package             4 The integration of contraceptive supplies
(UNMHCP), there should be a continued effort              into a financing mechanism
to ensure adequate funding of the budget line
for contraceptives. The current trend of govern-        Reproductive health, including access to supplies,
ment funding for the health sector shows that           is a priority area in Uganda’s Poverty Eradication
there has been a decline in health spending, and        Action Plan, which even sets a concrete target for
money allocated to the PAF budget line item for         the reduction of supply stockouts. Theoretically,
contraceptives remains mostly unspent or redi-          RH supplies should be an integral component of
rected. This pattern obviously is at odds with the      the PAF supporting the PEAP and other health
National Health Policy, so steps should be taken        sector financing, but spending remains low. The
to reverse the decreasing funding, at least until the   government’s stagnant relative funding for the
Abuja Declaration commitment of allocating 15           health sector may be a signal that it perceives
percent of the budget to the health sector is met.      donor funds to be protected and guaranteed: The
Parliamentarians active in the maternal health          government is well aware that “donors are not
network have already served as effective advo-          going to let commodities run out and are ready
cates, pressuring the government to be completely       to step in when necessary.”58 However, the shift
transparent about its contributions to FP/RH by         towards country ownership is already underway
threatening not to pass the health budget.              among many donors and the government is likely
                                                        to face increasing responsibilities for financing
The issue of decentralization affects funding for       Uganda’s development. Advocacy efforts could
RH supplies in addition to coordination. “One           focus on strengthening government commitment
of the main challenges to ensuring commodity            to use its own resources for RH supplies, for ex-
security and promoting a demand for family plan-        ample by ensuring the PAF contraceptive budget
ning…is the problem of translating the national         line item is fully disbursed.
RH agenda into concrete action at district level.”57
Given that supplies challenges are occurring            Uganda is currently planning the development
below the central level, the decentralization of        of a National Health Insurance Scheme. It will
Uganda’s health system reinforces the need for tar-     be critical to ensure that RH supplies are fully
geted advocacy among districts and communities.         included in the list of covered services. In Ghana,
Noting that no districts are currently using their      for example, the recent roll-out of an insurance
own budgets for contraceptives, one government          scheme that neglected contraceptives was a tre-
official stated that “advocacy at the national level    mendous missed opportunity to expand access to
doesn’t help women get the contraceptives they          services and supplies.

     During three trips to Kampala in December 2007, April 2008 and March 2009, members of the
     Project RMA research team (Susan Anderson, Jessica Bernstein, Jennifer Johnson, Elizabeth Leahy, Kate
     Tibone and Carolyn Vogel, all of PAI) met with the following individuals. We are very grateful for the
     time and information each of them shared with us.

     Dr. Angela Akol, Project Director, Family Health    Peter Ogwang Ogwal, Programme Officer,
     International                                       DANIDA
     Hannington Burunde, Head, Information               Dr. Olive Sentumbwe-Mugisa, National Profes-
     and Communication Department, Population            sional Officer, Family Health and Population,
     Secretariat, Ministry of Finance, Planning and      World Health Organization
     Economic Development                                Anne Sizomu, Training Manager, DSW Uganda
     Dr. Henry Kakande, EngenderHealth                   Hon. Sylvia Ssinabulya, Member of Parliament
     James Kotzsch, Country Director, DSW Uganda         (Mityana District)
     Dr. Betty Kyaddondo, East African Reproduc-         Dr. Krista Stewart, Social Science Analyst,
     tive Health Network                                 USAID
     Mona Herbert, Advocacy and Communication            Dr. Michael Strong, PEPFAR Coordinator, U.S.
     Officer, DSW Uganda                                 Embassy
     Catherine Mbabazi, Nation Programme Officer,        Sereen Thadeus, Senior Technical Advisor,
     Monitoring and Evaluation Department, Popula-       USAID/Uganda
     tion Secretariat, Ministry of Finance, Planning     Bernard Tusiime, Senior Projects Coordinator,
     and Economic Development                            DSW Uganda
     Dr. Anthony Mbonye, Assistant Commissioner,
     Reproductive Health Division, Ministry of Health
     Thomas Mega, Country Director, Marie Stopes
     Hassan Mohtashami, Deputy Representative,
     Elly Mugumya, Executive Director,Reproductive
     Health Uganda
     Paschal Mujasi, Deputy Chief of Party/General
     Logistics Advisor, JSI, USAID/DELIVER Project
     Jotham Musinguzi, Partners in Population and
     Development, East African Regional Office
     Moses Muwonge, National RH Commodity
     Security Coordinator, Ministry of Health
     Grace Nagendi, FP-HIV Integration Coordina-
     tor, EngenderHealth
     Hon. Nansubuga Sarah Nyombi, Member of
     Parliament (Ntenjeru North)


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     1    These indicators are shared with UNFPA’s Global   36   RHInterchange. Available at;
          Programme for Reproductive Health Commodity            last accessed 9 April 2009. These data reflect dates
          Security.                                              of shipment, which do not necessarily correspond
     2    Reproductive Health Uganda.                            to when funding was disbursed or when supplies
     3    Khan et al, 2008. p. 1                                 were received

     4    Apunyo, 2008                                      37   Anyanwu, p. 11.

     5    Baguma and Ogwang 2009.                           38   Kelly, 2006

     6    Macro International Inc, 2009. MEASURE DHS        39   Personal interview, 6 March 2009.
          STATcompiler.,          40   Personal interview, 7 March 2009.
          April 7 2009                                      41   Contraceptive Stock Status at National Medical
     7    WHO, 2007. p. 27                                       Stores, February 25, 2009. Obtained at personal
     8    Khan et al, 2008. p. 1                                 interview, 3 March 2009.

     9    Baguma and Ssengendo 2008.                        42   DELIVER 2007; Personal interviews, 6 and 7
                                                                 March 2009.
     10   Roadmap draft, p. 13
                                                            43   Chattoe-Brown et al, p. 2.
     11   Ministry of Finance, Planning and Economic
          Development.                                      44   DELIVER 2007, p. 3

     12   POLICY Project 2005.                              45   MOH 2008a (draft), pp. 31-32.

     13   Kyaddondo 2005.                                   46   Anyanwu, p. 10.

     14   Personal interview, 10 March 2009.                47   DELIVER 2007, p. 26.

     15   DELIVER 2007.                                     48   Anyanwu, pp. 11-12.

     16   Roadmap Draft, pp. 6-7.                           49   Ibid, p. 48

     17   Ortendahl, 2007 p. 2                              50   MOH 2008a (draft), p. 21.

     18   DELIVER 2007, p. 1.                               51   DELIVER 2007, p. 38

     19   DELIVER 2007.                                     52   DELIVER 2007, p. 2

     20   Ortendahl, 2007 pp. 1-2                           53   DELIVER 2007, p. 53

     21   UNFPA 2007, p. 22                                 54   UBOS, 2001, p. 6

     22   Glengaard et al, 2006. p. 13                      55   MOH 2008a (draft), p. 2.

     23   Personal interview, 4 March 2009.                 56   Anyanwu, pp.21-22.
     24   MOH 2008a (draft), p. 17.                         57   Chattoe-Brown and Bitunda, p. 8.

     25   MOH 2008a (draft), p. 18.                         58   Chattoe-Brown and Bitunda, p. 19.

     26   Anyanwu, p. 8.
     27   Personal interview, 4 March 2009.
     28   Kelly, 2006
     29   Personal interview, 7 March 2009.
     30   Personal interview, 4 March 2009; MOH 2008a
          (draft), p. 15.
     31   Personal interview, Ministry of Health, 4 March
     32   USAID | DELIVER, p. 5
     33   Naluyiga 2009.
     34   MOH 2008a (draft), pp. 15-16.
     35   MOH 2008a (draft), p. 10.

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